I forgot to note that the doctor "shortage" will be also addresed by having nurse practitioners and physician assistants do what we do.

In a way, if control of health care goes the way the elites want this may not be unreasonable. Indeed we won't need doctors at all except to do the most complex tasks or the very sickest intensive care. Every aspect of medical care will be cook book and anyone can follow down the path of computer programs that spit out what to do in any given moment.

There will be all sorts of statician studies "proving" that care will be just as good, that "outcomes" for large populations will be the same.

As a primary care physician I am used to being devalued. So I am neither shocked or even care at this point.

It would be like replacing trained experienced police officers with auxillary police, or attorneys with paralegals and giving them cook books to follow.

Then pointing out how violent crime is not up, just as many traffick tickets are given out and that civil legal situation is just as dandy as before.

"having nurse practitioners and physician assistants do what [doctors] do"

Except that with public unionization and lack of market discipline on costs and efficiencies, we will be paying the less qualified as much as we would or could have been paying the MD's IMO.

As far as I know the physician shortage is matched with a system of keeping good people out. The extreme salaries needed to pay doctors (in the eyes of others) comes from the limits on supply and the artificially high cost of higher eduction. Medical schools have no constraints on costs either until people quit applying and entering at those prices.

I'm waiting for my libertarian friends to call for legalization of private, unlicensed health care if we are moving toward less trained and less qualified practitioners anyway.

Well there is a lot of fear amongst doctors of "going out of business" and having to lay people off. I am surprised at what I am hearing. Of course not all areas of the country are like the NYC metropolitan area which has had plenty of doctors.

A cardiologist today told of taking a pay cut from his group and of another one being let go.

I am a bit surpirsed in view of how much they have made for years.

As for me I have gotten nothing for years and expect nothing. I am not holding my breath for "saving primary care".

In fact the plan as I see it is simply to replace us with nurses though few are coming out and saying that now till after as many elections as they can put this off for.

All I can say for certain if seniors want to bitch about the cost of their medicines prior to W's part D plan that went into effect, and then complain still about thier Rx costs that fall into the "donut holes", then just wait till Bama and his ideological policy makers (who are drooling at the thought of getting control, power and making plenty of dough) get done with them.

The "greatest" generation that now expects to sit back and let us pay may be the biggest bunch of crab apples pretty soon.

Then comes the "boomers" getting into the Medicare slots (which I guess I am one) and need I say more?

The Insurance Mandate in PerilFirst Congress said it was a regulation of commerce. Now it's supposed to be a tax. Neither claim will survive Supreme Court scrutiny.By RANDY E. BARNETT

A"tell" in poker is a subtle but detectable change in a player's behavior or demeanor that reveals clues about the player's assessment of his hand. Something similar has happened with regard to the insurance mandate at the core of last month's health reform legislation. Congress justified its authority to enact the mandate on the grounds that it is a regulation of commerce. But as this justification came under heavy constitutional fire, the mandate's defenders changed the argument—now claiming constitutional authority under Congress's power to tax.

This switch in constitutional theories is a tell: Defenders of the bill lack confidence in their commerce power theory. The switch also comes too late. When the mandate's constitutionality comes up for review as part of the state attorneys general lawsuit, the Supreme Court will not consider the penalty enforcing the mandate to be a tax because, in the provision that actually defines and imposes the mandate and penalty, Congress did not call it a tax and did not treat it as a tax.

The Patient Protection and Affordable Care Act (aka ObamaCare) includes what it calls an "individual responsibility requirement" that all persons buy health insurance from a private company. Congress justified this mandate under its power to regulate commerce among the several states: "The individual responsibility requirement provided for in this section," the law says, ". . . is commercial and economic in nature, and substantially affects interstate commerce, as a result of the effects described in paragraph (2)." Paragraph (2) then begins: "The requirement regulates activity that is commercial and economic in nature: economic and financial decisions about how and when health care is paid for, and when health insurance is purchased."

In this way, the statute speciously tries to convert inactivity into the "activity" of making a "decision." By this reasoning, your "decision" not to take a job, not to sell your house, or not to buy a Chevrolet is an "activity that is commercial and economic in nature" that can be mandated by Congress.

It is true that the Supreme Court has interpreted the Commerce Clause broadly enough to reach wholly intrastate economic "activity" that substantially affects interstate commerce. But the Court has never upheld a requirement that individuals who are doing nothing must engage in economic activity by entering into a contractual relationship with a private company. Such a claim of power is literally unprecedented.

Since this Commerce Clause language was first proposed in the Senate last December, Democratic legislators and law professors alike breezily dismissed any constitutional objections as preposterous. After the bill was enacted, critics branded lawsuits by state attorneys general challenging the insurance mandate as frivolous. Yet, unable to produce a single example of Congress using its commerce power this way, the defenders of the personal mandate began to shift grounds.

On March 21, the same day the House approved the Senate version of the legislation, the staff of the Joint Committee on Taxation released a 157-page "technical explanation" of the bill. The word "commerce" appeared nowhere. Instead, the personal mandate is dubbed an "Excise Tax on Individuals Without Essential Health Benefits Coverage." But while the enacted bill does impose excise taxes on "high cost," employer-sponsored insurance plans and "indoor tanning services," the statute never describes the regulatory "penalty" it imposes for violating the mandate as an "excise tax." It is expressly called a "penalty."

This shift won't work. The Supreme Court will not allow staffers and lawyers to change the statutory cards that Congress already dealt when it adopted the Senate language.

In the 1920s, when Congress wanted to prohibit activity that was then deemed to be solely within the police power of states, it tried to penalize the activity using its tax power. In Bailey v. Drexel Furniture (1922) the Supreme Court struck down such a penalty saying, "there comes a time in the extension of the penalizing features of the so-called tax when it loses its character as such and becomes a mere penalty with the characteristics of regulation and punishment."

Although the Court has never repudiated this principle, the Court now interprets the commerce power far more broadly. Thus Congress may regulate or prohibit intrastate economic activity directly without invoking its taxation power. Yet precisely because a mandate to engage in economic activity has never been upheld by the Court, the tax power is once again being used to escape constitutional limits on Congress's regulatory power.

Supporters of the mandate cite U.S. v. Kahriger (1953), where the Court upheld a punitive tax on gambling by saying that "nless there are provisions extraneous to any tax need, courts are without authority to limit the exercise of the taxing power." Yet the Court in Kahriger also cited Bailey with approval. The key to understanding Kahriger is the proposition the Court there rejected: "it is said that Congress, under the pretense of exercising its power to tax has attempted to penalize illegal intrastate gambling through the regulatory features of the Act" (emphasis added).

In other words, the Court in Kahriger declined to look behind Congress's assertion that it was exercising its tax power to see whether a measure was really a regulatory penalty. As the Court said in Sonzinsky v. U.S. (1937), "nquiry into the hidden motives which may move Congress to exercise a power constitutionally conferred upon it is beyond the competency of courts." But this principle cuts both ways. Neither will the Court look behind Congress's inadequate assertion of its commerce power to speculate as to whether a measure was "really" a tax. The Court will read the cards as Congress dealt them.

Congress simply did not enact the personal insurance mandate pursuant to its tax powers. To the contrary, the statute expressly says the mandate "regulates activity that is commercial and economic in nature." It never mentions the tax power and none of its eight findings mention raising any revenue with the penalty.

Moreover, while inserting the mandate into the Internal Revenue Code, Congress then expressly severed the penalty from the normal enforcement mechanisms of the tax code. The failure to pay the penalty "shall not be subject to any criminal prosecution or penalty with respect to such failure." Nor shall the IRS "file notice of lien with respect to any property of a taxpayer by reason of any failure to pay the penalty imposed by this section," or "levy on any such property with respect to such failure."

In short, the "penalty" is explicitly justified as a penalty to enforce a regulation of economic activity and not as a tax. There is no authority for the Court to recharacterize a regulation as a tax when doing so is contrary to the express and actual regulatory purpose of Congress.

So defenders of the mandate are making yet another unprecedented claim. Never before has the Court looked behind Congress's unconstitutional assertion of its commerce power to see if a measure could have been justified as a tax. For that matter, never before has a "tax" penalty been used to mandate, rather than discourage or prohibit, economic activity.

Are there now five justices willing to expand the commerce and tax powers of Congress where they have never gone before? Will the Court empower Congress to mandate any activity on the theory that a "decision" not to act somehow affects interstate commerce? Will the Court accept that Congress has the power to mandate any activity so long as it is included in the Internal Revenue Code and the IRS does the enforcing?

Yes, the smart money is always on the Court upholding an act of Congress. But given the hand Congress is now holding, I would not bet the farm.

Mr. Barnett is a professor of constitutional law at Georgetown and the author of "Restoring the Lost Constitution: The Presumption of Liberty" (Princeton, 2005).

ShareCloseLinkedinDiggFacebookMixxMySpaceYahoo! BuzzPermalink Published: May 2, 2010 Americans are already starting to see the benefits of health care reform. The new law requires health insurance companies — starting in September — to end their most indefensible practice: rescinding coverage after a policyholder gets sick. In recent days insurers and their trade association have rushed to announce that they will end rescissions immediately.

Skip to next paragraph Editorial SeriesHealth Care ReformReaders' CommentsReaders shared their thoughts on this article.Read All Comments (135) »That is very good news for the thousands of people who each year pay their premiums but lose their coverage just when they are likely to run up big medical bills.

The insurers decided to act quickly after they were whacked by some very bad publicity. An investigative report by Reuters said that one of the nation’s biggest insurers, WellPoint, was targeting women with breast cancer for fraud investigations that could lead to rescissions.

Although WellPoint fiercely denied singling out breast cancer patients for scrutiny, it acknowledged using computer algorithms to search for a range of conditions that applicants would likely have known about at the time they applied. That seemed like a backhanded admission that it was indeed searching for excuses — the company would say legitimate reasons — to cancel coverage. The Obama administration and Congressional Democrats urged insurers to end rescissions at once.

Insurers claim policies are rescinded only when people have misrepresented or lied about their health status or other important factors at the time of application. Insurers do rescissions only on individual policies, not employer-based coverage. They argued that to keep down rates for the rest of their customers they needed the ability to exclude people who failed to report pre-existing conditions.

An investigation and hearings last year by the House Committee on Energy and Commerce challenged those claims. They found many troubling cases where the pre-existing conditions were trivial, unrelated to the claim, or not known to the patient.

Some companies issued policies quickly to start collecting premiums and only later, if a policyholder filed expensive claims, performed a detailed examination of medical records. If they found any discrepancies or omissions, they would retroactively cancel the policy, refund the premiums paid, and refuse to pay for further medical services. At that point, of course, the applicant would be unable to get coverage from any other insurer.

The House investigation found that three big insurers rescinded some 20,000 policies over a five-year period, and a survey by the National Association of Insurance Commissioners found more than 27,000 rescissions in an overlapping five-year period. That’s a small percentage of the millions of policies issued or in force in any given year, but a disaster for the thousands of people who lost their insurance.

The insurers were wise to short-circuit the criticisms and end rescissions now. This follows a recent agreement by many companies to start letting dependents stay on their parents’ policies until age 26, which isn’t required until September. Under pressure from the White House, the industry has also agreed to cover children with pre-existing medical conditions as soon as new rules are issued.

Many of the other major provisions of reform don’t kick in until 2014, but it is already changing the behavior of insurers. That means more security for many Americans who might otherwise find insurance unaffordable or unavailable

The good parts of healthcare could have been done with bipartisanmaybe unanimous majority. It makes a lie (IMO)of the promise to unite, not divide. I can't imagine a Republican opposing this. I can't imagine an informed consumer paying for a policy while healthy that does not continue to cover you later when you are not.

The leftists in charge would not give us basic, obvious protections that people wanted without mixing them with the unpopular provisions of socialism, mandates, and new taxes in order to get the end result that they wanted.

NEW ORLEANS -- Just five weeks since the president of the United States signed Obamacare into law, it already resembles an overweight airplane lumbering down the tarmac, poised to crash and burn soon after takeoff. Obamacare's excess cargo of broken promises threatens such a catastrophe.

Not so fast, warns Medicare's Office of the Actuary. In a devastating, independent, 38-page analysis released on April 22, Chief Actuary Richard Foster forecast, "The growth rate reductions from productivity adjustments are unlikely to be sustainable on a permanent annual basis . . . We show a negligible financial impact over the next 10 years for the other provisions intended to help control future health-care cost growth."

"This is an objective report by administration actuaries that shows this sweeping legislation has serious, serious problems," says health-policy analyst Grace-Marie Turner of the Galen Institute. Foster's study delineates the canyon between Obama's warm words and the chilly disappointment that awaits those who expect Obamacare to do good.

"We will have a health-care plan that actually works for you, reduces spending and costs over the long term," Obama promised at the Oct. 7, 2008 presidential debate, among other appearances.

In fact, Foster calculates, the plan will boost U.S. health spending by $311 billion through 2019, while federal medical outlays will grow "by a net total of $251 billion."

"If you like your health-care plan, you will be able to keep your health-care plan. Period. No one will take it away. No matter what," Obama promised the American Medical Association last June 15, and on numerous other occasions.

This guarantee will turn to dust, Foster predicts. "Some smaller employers would be inclined to terminate their existing coverage," he explains. Elsewhere, "the penalties would not be a substantial deterrent to dropping or foregoing coverage." Thanks to these and similar factors, "We estimate that such actions would collectively reduce the number of people with employer-sponsored health coverage by about 14 million," Foster writes.

NEW ORLEANS -- Just five weeks since the president of the United States signed Obamacare into law, it already resembles an overweight airplane lumbering down the tarmac, poised to crash and burn soon after takeoff. Obamacare's excess cargo of broken promises threatens such a catastrophe.

Not so fast, warns Medicare's Office of the Actuary. In a devastating, independent, 38-page analysis released on April 22, Chief Actuary Richard Foster forecast, "The growth rate reductions from productivity adjustments are unlikely to be sustainable on a permanent annual basis . . . We show a negligible financial impact over the next 10 years for the other provisions intended to help control future health-care cost growth."

"This is an objective report by administration actuaries that shows this sweeping legislation has serious, serious problems," says health-policy analyst Grace-Marie Turner of the Galen Institute. Foster's study delineates the canyon between Obama's warm words and the chilly disappointment that awaits those who expect Obamacare to do good.

"We will have a health-care plan that actually works for you, reduces spending and costs over the long term," Obama promised at the Oct. 7, 2008 presidential debate, among other appearances.

In fact, Foster calculates, the plan will boost U.S. health spending by $311 billion through 2019, while federal medical outlays will grow "by a net total of $251 billion."

"If you like your health-care plan, you will be able to keep your health-care plan. Period. No one will take it away. No matter what," Obama promised the American Medical Association last June 15, and on numerous other occasions.

This guarantee will turn to dust, Foster predicts. "Some smaller employers would be inclined to terminate their existing coverage," he explains. Elsewhere, "the penalties would not be a substantial deterrent to dropping or foregoing coverage." Thanks to these and similar factors, "We estimate that such actions would collectively reduce the number of people with employer-sponsored health coverage by about 14 million," Foster writes.(2 of 2)

"I can make a firm pledge," Obama told Dover, New Hampshire voters on Sept. 12, 2008. "Under my plan, no family making less than $250,000 a year will see any form of tax increase. Not your income tax, not your payroll tax, not your capital gains taxes, not any of your taxes."

Obamacare's first 10 years of operations would cost $2.5 trillion. This massive new expenditure, plus Washington's other spendaholic commitments, explains Obama's eagerness to jettison his oft-repeated commitment not to raise taxes on Americans who earn less than $250,000 annually.

To finance Obamacare and their other pricey projects, many Washington Democrats crave a national sales tax. Obamacare already features $569 billion in new taxes on -- among other things -- prescription drugs, medical devices, health insurance plans, and even tanning salons. These levies will trickle down to couples with annual incomes below $250,000, and individuals under $200,000. Rather than keep his promise, Obama triumphantly signed these health-related tax hikes.

Regarding a national sales levy -- atop the income tax and countless tributes that tread on Americans as if with cleated boots -- Obama refuses to reject it. In fact, Americans for Tax Reform noted Obama's remarks as he introduced his deficit commission on Tuesday: "It's important that we not restrict the review or the recommendations that this commission comes up with in any way. Everything has to be on the table."

Unveiled in 2008, "Barack Obama's Plan for a Healthy America" was designed for "Making health insurance universal."

After all this hassle and expense, Richard Foster concludes, "an estimated 23 million people{$326} would remain uninsured in 2019."

Before Obamacare gets airborne, only to plow swiftly into a nearby cornfield, this Congress -- or a clean one elected next November -- urgently must cancel this flight, disembark its enraged passengers and replace this rusty bucket with a viable aircraft.

Finally we are beginning the hear in the media what the academics at Harvard and a few other liberal ivory towers have in store for us as they have planned for decades. Please recall how I have said these are the handful of people who are pushing for government controlled socialized medicine. Now that this guy is pushed out there as the new leader of the radical overhaul of our health care system in the US we are finally seeing him scrutinized. The goal certainly is single payer, no choice, government controlled and dictated care to all of us. No execptions. Is it finally clear to the nay sayers yet or not?

****Donald Berwick’s Radical Agendaby Ben Domenech

President Obama’s nomination of Donald Berwick as the head of the Centers for Medicare and Medicaid Services (CMS) is a gathering far less attention than a certain other nominee — but it will be getting more attention in the weeks to come, given his particularly radical agenda when it comes to health policy.

Berwick is a leading Ivy League academic and technocrat – he’s graduated from Harvard not once, but three times – and is the founder of a Cambridge-based think-tank, the Institute for Health Care Improvement. Yet the job of running CMS is hardly the same as running a small think tank or talking in broad terms about the nature of health care – CMS is essentially the world’s second largest insurance company after the United Kingdom’s NHS, covering over 98 million people and overseeing roughly $800 billion annually in taxpayer-funded health care expenditures.

Berwick is a great fan of the NHS, and worked as a consultant on the project under Tony Blair. Berwick will have the opportunity to apply the ideas he gained through that experience with the power of the CMS position, which means that his nomination holds massive ramifications for Medicare and Medicaid recipients, hospitals and doctors and, under Obama’s law, all Americans.

Berwick: Health Care Must Redistribute Wealth

Key to understanding Berwick’s views on the NHS is a speech he gave as part of a presentation offered two years ago, in which he shared his thoughts on the NHS and health care generally. You can watch the full speech here, which is excerpted above. The full video shows several lines from Berwick that are notable. He decries private sector solutions to health care problems, dismissing the “invisible hand of the market” as an “unaccountable system.” He also states:

“I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country.”

And more disturbingly, in the clip above:

“Any health care funding plan that is just equitable civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.”

Berwick’s Views on Why the US Should Be More Like the UK

Robert Goldberg, vice president of the Center for Medicine in the Public Interest, writes on Berwick’s views expressed in 2008 at length in this piece at the American Spectator:

“Berwick complained the American health system runs in the ‘darkness of private enterprise,’ unlike Britain’s ‘politically accountable system.’ The NHS is ‘universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just’; America’s health system is ‘toxic,’ ‘fragmented,’ because of its dependence on consumer choice. He told his UK audience: ‘I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.’”

But as Goldberg points out:

“It may not be joyous or just or configured correctly, but for nearly every disease, particularly cancer, stroke, and heart attacks, Americans live longer and healthier than the English because of better care.”

Indeed, the UK has a terrible record on heart attacks, cancer, and more. A recent piece in the Telegraph runs down the OECD numbers concerning Britain’s actual outcomes from the system Berwick supports so much:

“Britain also languishes near the bottom of the breast cancer league table, with a survival rate of 78.5 per cent. The OECD-wide average is 81.2 per cent. Heart attack victims in Britain are also more likely to die after entering hospital than in most other developed nations. Around 6.3 per cent of patients who have suffered a heart attack have passed away within 30 days of entering a British hospital – significantly higher than the 4.3 per cent average. The figures also show that British life expectancy is much lower than our nearest neighbours. Men in this country can expect to live to 79 years and six months, against 81 years in France. While the report’s authors identified some successes in British healthcare – we have among the best records in Europe for screening women for breast and cervical cancer – the survey indicates that Labour’s much-trumpeted NHS investment has failed to raise standards in key areas.”

The fact is that the UK system is designed for a very different population than ours, with a very different culture — one with far fewer guns, auto accidents, better diets, and fewer young people doing dangerous things. Yet America still has advantages in dealing with these key diseases. While there are many statistics to trumpet on this point, perhaps the best example is that American life expectancy at age 65 is actually higher than Britain.

Berwick: Best System is Ration-Based Single Payer

Berwick is not so much an ideologue as a true believer in governmental efficiency over the ability of the marketplace and the consumer to direct their health care. In a recent piece in Health Affairs, written along with two colleagues, Berwick details his position on the ideal nature of health care:

“If we could ever find the political nerve, we strongly suspect that financing and competitive dynamics such as the following, purveyed by governments and payers, would accelerate interest in [our policy ideal] and progress toward it: (1) global budget caps on total health care spending for designated populations, (2) measurement of and fixed accountability for the health status and health needs of designated populations, (3) improved standardized measures of care and per capita costs across sites and through time that are transparent, (4) changes in payment such that the financial gains from reduction of per capita costs are shared among those who pay for care and those who can and should invest in further improvements, and (5) changes in professional education accreditation to ensure that clinicians are capable of changing and improving their processes of care. With some risk, we note that the simplest way to establish many of these environmental conditions is a single-payer system, hiring integrators with prospective, global budgets to take care of the health needs of a defined population, without permission to exclude any member of the population.”

As the eloquent Avik Roy wrote recently, there are serious flaws in Berwick’s approach (emphasis mine):

“First off, as William Schambra observed in National Affairs, it assumes that politicians — and politics — play no role in forming health-care policy. Even if you believe that technocrats could better organize our health-care system, Berwick’s approach only works if the narrow interests of Congressmen, labor unions, general hospitals, the AARP, etc., have no influence on the writing of law. No one who watched Democrats make the Obamacare sausage can harbor any illusions on this score.

“Secondly, as Friedrich Hayek pointed out back in 1945, the command approach is doomed to fail because its commanders do not gain accurate information about what is happening on the ground. Technocrats may believe they can marshal statistics and analysis to optimize the health-care system, but they are not omniscient. Their analyses rely on too many assumptions and on unreliable data. This is why government programs always result in colossal amounts of waste, fraud, and abuse. On the other hand, a truly free market for health insurance could efficiently allocate health-care resources to those therapies and tests that patients and doctors most need.”

Yet Berwick is not particularly ideological in his endorsement: he simply believes that the single payer model is the most efficient, and the most easily managed, approach to health care. In large part, this is because he believes in government-directed rationing of care.

In an interview on Comparative Effectiveness Research, Berwick supported an agency which would rationing health care. He particularly focused on what he perceives as the benefits of the UK’s National Institute for Clinical Health and Excellence: As Dr. Berwick said:

“NICE is extremely effective and a conscientious, valuable, and — importantly — knowledge-building system [which has] developed very good and very disciplined, scientifically grounded, policy-connected models for the evaluation of medical treatments from which we ought to learn.”

The interviewer pointed out: “Critics of CER have said that it will lead to the rationing of health care.” To which Berwick replied: “The decision is not whether or not we will ration care. The decision is whether we will ration with our eyes open.”

Here are just some of the horror stories from NICE over the past several years. Under Donald Berwick’s authority as the head of CMS, get ready to see stories like these in the pages of American papers in the years to come.*****

y SCOTT GOTTLIEB President Obama guaranteed Americans that after health reform became law they could keep their insurance plans and their doctors. It's clear that this promise cannot be kept. Insurers and physicians are already reshaping their businesses as a result of Mr. Obama's plan.

The health-reform law caps how much insurers can spend on expenses and take for profits. Starting next year, health plans will have a regulated "floor" on their medical-loss ratios, which is the amount of revenue they spend on medical claims. Insurers can only spend 20% of their premiums on running their plans if they offer policies directly to consumers or to small employers. The spending cap is 15% for policies sold to large employers. This regulation is going to have its biggest impact on insurance sold directly to consumers—what's referred to as the "individual market." These policies cost more to market. They also have higher medical costs, owing partly to selection by less healthy consumers. Finally, individual policies have high start-up costs. If insurers cannot spend more of their revenue getting plans on track, fewer new policies will be offered.

This will hit Wellpoint, one of the biggest players in the individual market, particularly hard. The insurance company already has a strained relationship with the White House: Earlier this month Mr. Obama accused Wellpoint of systemically denying coverage to breast cancer patients, though the facts don't bear that out.

Restrictions on how insurers can spend money are compounded by simultaneous constraints on how they can manage their costs. Beginning in 2014, a new federal agency will standardize insurance benefits, placing minimum actuarial values on medical policies. There are also mandates forcing insurers to cover a lot of expensive primary-care services in full. At the same time, insurers are being blocked from raising premiums—for now by political jawboning, but the threat of legislative restrictions looms.

One of the few remaining ways to manage expenses is to reduce the actual cost of the products. In health care, this means pushing providers to accept lower fees and reduce their use of costly services like radiology or other diagnostic testing.

To implement this strategy, companies need to be able to exert more control over doctors. So insurers are trying to buy up medical clinics and doctor practices. Where they can't own providers outright, they'll maintain smaller "networks" of physicians that they will contract with so they can manage doctors more closely. That means even fewer choices for beneficiaries. Insurers hope that owning providers will enable health policies to offset the cost of the new regulations.

Doctors, meanwhile, are selling their practices to local hospitals. In 2005, doctors owned more than two-thirds of all medical practices. By next year, more than 60% of physicians will be salaried employees. About a third of those will be working for hospitals, according to the American Medical Association. A review of the open job searches held by one of the country's largest physician-recruiting firms shows that nearly 50% are for jobs in hospitals, up from about 25% five years ago.

Last month, a hospital I'm affiliated with outside of Manhattan sent a note to its physicians announcing a new subsidiary it's forming to buy up local medical practices. Nearby physicians are lining up to sell—and not just primary-care doctors, but highly paid specialists like orthopedic surgeons and neurologists. Similar developments are unfolding nationwide.

Consolidated practices and salaried doctors will leave fewer options for patients and longer waiting times for routine appointments. Like the insurers, physicians are responding to the economic burdens of the president's plan in one of the few ways they're permitted to.

For physicians, the strains include higher operating costs. The Obama health plan puts expensive new mandates on doctors, such as a requirement to purchase IT systems and keep more records. Overhead costs already consume more than 60% of the revenue generated by an average medical practice, according to a 2007 survey by the Medical Group Management Association. At the same time, reimbursement under Medicare is falling. Some specialists, such as radiologists and cardiologists, will see their Medicare payments fall by more than 10% next year. Then there's the fact that medical malpractice premiums have risen by 10%-20% annually for specialists like surgeons, particularly in states that haven't passed liability reform.

The bottom line: Defensive business arrangements designed to blunt ObamaCare's economic impacts will mean less patient choice.

Dr. Gottlieb, a former official at the Centers for Medicare and Medicaid Services, is a fellow at the American Enterprise Institute and a practicing internist. He's partner to a firm that invests in health-care companies.

They will decide everything along ideological and politically expedient lines to the benefit of the "buddies" of whichever party. More yearly changes to the system in the interests of "fairness" which have made taxes such a snarl of loopholes, subsidies and favors. I was talking to a Brit on the strip the other day while waiting to see BlueMan. He was saying that people waiting for joint replacements were waiting upwards of 2 years if they were on the government insurance. The private insured option usually had them done in a month or less after pre-operation prep/precautions were tended to.

Few Americans know what a “medical loss ratio” is, but a fierce struggle over how to calculate it under the new health care reform law will determine how much insurers must spend on patient care and how much they can retain for administration and profits. This is but one of many battles that will emerge as federal and state regulators develop regulations to implement reform.

The new law requires health insurers, starting in 2011, to spend at least 80 to 85 percent of the premiums they collect on medical services or activities that improve the quality of care. (That percentage is the medical loss ratio.) The remainder can be allocated to profits or administrative activities that do not directly benefit patients, such as marketing, overhead and salaries.

The law leaves plenty of room for finagling over what can be counted as a quality improvement activity. The National Association of Insurance Commissioners, which is helping the administration develop standards, is being lobbied by insurers to adopt a broad definition and by consumer advocates to keep it narrow.

Some insurers are clearly overreaching. They argue that much of the cost of setting up networks of providers should count as quality improvement, because they check the credentials and disciplinary records of doctors. They want to include programs to root out fraud or overbilling because they probably weed out some bad doctors as well. And they would include the cost of programs, including precertification, that judge whether care is covered and appropriate. All these look like activities whose primary purpose is to reduce costs for the insurer with quality at best a secondary issue.

Senator Jay Rockefeller, chairman of the commerce committee, says his staff has found that insurers are already reclassifying many administrative costs as medical expenses to create the appearance of a higher medical loss ratio. He is rightly urging a rigorous standard.

Sensible boundaries can surely be drawn. Health information technology that improves patient care by preventing drug interactions should clearly count, but technology that primarily streamlines business operations should not. Programs that help manage and coordinate the care given chronically ill patients should count, but programs that review whether doctor-recommended services are covered should not.

Regulators will have to find an approach that prevents insurers from gaming the system while encouraging them to spend money on meaningful measures to improve quality — a major goal of the reform law.

And Rusmussan reports Bamster's (Rush's nickname for the phoney ONE) approval at 44% though this low level was reported before.

If only the Cans can get their act together!?

Doug, I hope you are right and there is some sort of "Contract with America" again.

I am hoping they are saving coming out with a contract list till closer to crunch time rather than give away their eggs now. Yet in this day and age and as I have learned from the music business it is impossible to keep people for finding out one's ideas anyway.

That aside if the cans can come up with something a contract I think they can run away to *crushing* victory in Nov and not just win by default.

I believe A Lame Duck Bamster without his adoring majority in both houses will fold in the face of the opposition.

As for Contract with America, Newt appears to be planning a run. Can he overcome previously terrible ratings though? I dunno.

"Doug, I hope you are right and there is some sort of "Contract with America" again. "

In 1994 that was done very late in the campaign and these were all very highly poll tested proposals. It stole the oxygen away from their opponents and it answered the main complaint of the opponents - we know what you are against, but you never tell us how you would govern. The Contract did that.

2006 was the opposite. As Democrats were coasting to a negative victory - people were going to elect Bush's opposition. Pelosi went into hiding, either to heal her plastic surgery or to keep her San Francisco Liberal mug out of the local news or the moderate Dems running contested races across the heartland. The strategy of 2008-2008 was to downplay the leftist agenda because it doesn't stand up to scrutiny.

I don't know if Republicans need a Contract with America to win this year, but they need the experience and discipline of hammering one out in order to govern and to set the table for 2012. For 2012 we will need leaders that will agree to the principles, not Pied Piper types that will make some other song sound appealing.

Will the IRS Oversee Your Health Care?The Patient Protection and Affordable Care Act, which was signed into law on March 23, 2010, mandates that every American, with few exceptions, have health coverage starting in 2014. Failure to obtain required coverage will result in a penalty. For those whose household income is below set limits, there are federal tax credits to help make coverage affordable.

It is not clear how involved the Internal Revenue Service will be in enforcing the mandate. IRS Commissioner Shulman has indicated that the definition of "adequate health coverage" as required by the new law will be determined by the Department of Health and Human Services (not by the IRS). However, the IRS will create 1099 forms that insurance companies will use to inform the IRS of those with adequate coverage.

If the IRS learns that an individual does not have adequate coverage (presumably because no 1099 was received for that person), a letter will be sent about the penalty. The penalty could be withheld from any tax refunds owed to an individual without adequate health coverage. There are no criminal sanctions for failure to obtain coverage or to pay the penalty for lack of coverage.

The IRS will also do outreach to inform eligible taxpayers about tax credits available to help pay for health coverage.=========An MD friend writes:Good summary, As I understand it, the Insurance Company will send the original to the IRS then the individual receives two copies of the 1099. One goes with your return attached to W-2, the other for your records. The reality is, Most people will pay the fine and since there is no preexisting exclusion capability for private, exchange or government insurance, people will buy or apply for the policy when they need their Gall bladder out, their hernia fixed etc then drop it after its preformed and paid for. This is an old trick, currently, women buy a Blue's policy, get pregnant, see an OB-GYN and get accepted as a patient then drop their BCBS policy and pick up Medicaid. The OB is then obligated to deliver the child at a much reduced reimbursement. Even with the new bill, just as today, If the uninsured experiences an emergency it will be the old story--go to the ER get treated and don't pay the bill. For those of us who are MDs they have seen and experienced this many times. Sadly this healthcare bill now allows for a healthy, capable of hard work single fun loving 25 year old male to qualify for Medicaid. The only thing better is that when we legalize "medical marijuana" the tax payer can pay for both the healthcare and the "Medical Marijuana" to keep this 25 yo happy and healthy. The fact is most working people may financially be better off to not carry insurance, pay the fine, invest the difference and follow the above. Since HSAs are legislated to disappear why not save the money after tax where the Feds can only tax it instead of confiscate it when they take over the 401-ks, pension plans etc as has been discussed up there. Gamming the system is going to become an art form. For the rest of us who follow the law, healthcare will become more expensive.

As for marijauna the only real reason to legalize it is to take the profit out of the business as a criminal enterprise.

Medically I am not convinced of any value. It is just a bunch of middle aged (my generation) pot head hippies who want to smoke dope.

Almost without exception.

I met an ophthamologist in Florida who was harrased by the DEA like Katherine and I are harrased by the organizewd crime that runs the music business. His life was ruined. They stalked him, would get into his safety deposit boxes, go through his mail, listen in at his home, go through all his accounts, watch his associates, friends, and family. I guess he was pushing for the vague and questionable medicinal use of pot for glaucoma. It does seem to reduce eye pressures but spordically and unpredictably and from what I read not at all in a way that is comparable to real medicinals that are not available. I suppose it may have some anti-emitic effects in cancer treatment or with advanced AIDS, but mostly it seems to me the people pushing it are th post heads from the 60's and 70s.

Justice Department declares war on doctors In a landmark Idaho case, the Justice Department forced a group of doctors to accept government price controls.

By S.M. Oliva, Guest blogger / May 31, 2010

As I’ve long suspected, “health care reform” has emboldened the Justice Department to take a more active role in enforcing government price controls against physicians. Today the Antitrust Division, joined by Idaho Attorney General Lawrence Wasden, forced a a group of Boise orthopedists to accept price controls for worker’s compensation and HMO contracts as part of a settlement accusing the doctors of “price fixing”:

According to the complaint, the conspiring orthopedists engaged in two antitrust conspiracies, which took place from 2006 to 2008. In the first conspiracy, through a series of meetings and other communications, the orthopedists agreed not to treat most patients covered by workers’ compensation insurance.

They entered into a group boycott in order to force the Idaho Industrial Commission to increase the rates at which orthopedists were paid for treating injured workers. The Idaho Industrial Commission sets the fee schedule that determines the amount that orthopedists and other healthcare providers usually receive for treating patients covered by workers’ compensation insurance.

The boycott resulted in a shortage of orthopedists willing to treat workers’ compensation patients, causing higher rates for orthopedic services.

In the second conspiracy, all of the defendants, except [one], and other conspiring orthopedists agreed to threaten to terminate their contracts with Blue Cross of Idaho. They jointly threatened to terminate their contracts to force Blue Cross of Idaho to offer better contract terms to orthopedists.The proposed settlement prevents the Idaho Orthopaedic Society and the named orthopedists from agreeing with their competitors on fees and contract terms.

The settlement also prohibits them from collectively denying medical care to patients, refusing to deal with any payer or threatening to terminate contracts with any payer.

This case is a watershed for two reasons:

First, until now the Federal Trade Commission, not the Justice Department, has taken the lead in prosecuting physicians. Since 2000, the FTC has brought about three dozen cases against physicians (all but one of which settled without any trial). But the FTC only has civil and administrative jurisdiction; the Antitrust Division has civil and criminal jurisdiction. The Sherman Act makes no distinction between civil and criminal “price fixing,” so in a case like this, it’s entirely a matter of prosecutorial discretion whether to charge the doctors with a civil or criminal offense.

Based on the descriptions in the Antitrust Division’s press release, there’s certainly no reason they couldn’t have prosecuted the doctors criminally and insisted upon prison sentences — and there’s little doubt such threats were made or implied to obtain the physicians’ agreement to the proposed “settlement.”

The second reason this is a landmark case is that the Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing.”

The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices,” in the form of the Idaho Industrial Commission’s fee schedule.

The IIC administers the state’s worker compensation system and is composed of three commissioners appointed by the governor. This isn’t a quasi-private or semi-private entity. It’s a purely government operation.

What’s more, the Antitrust Division has linked a refusal to accept government price controls with a refusal to accept a “private” insurance company’s contract offer. This leaves little doubt that antitrust regulators consider insurance party contracts the equivalent of government price controls — and physicians and patients have no choice but to accept them.

The orthopedists who participated in these group boycotts denied medical care to Idaho workers and caused higher prices for orthopedic services.

Today’s action seeks to prevent the recurrence of these illegal acts and protects Idaho consumers by promoting competition in the healthcare industry.”

The Idaho attorney general compounds the lie:

The free marketplace works best when there is fair competition. Anticompetitive activity harms the marketplace, businesses and consumers.

Enforcement of the antitrust laws restores competition to the marketplace to the benefit of businesses and consumers and the marketplace as a whole.

But what “competition” do they refer to? The IIC fee schedule is set by government fiat. There’s no “competition” among orthopedists — or any other physicians for that matter. Everyone gets paid exactly the same “acceptable charges” based on the schedule. Even in the case of the Blue Cross contract, the physicians weren’t “competing” on price; they were simply told to accept the reimbursement levels proposed by the insurer.=======And as much as the government would tout the “conspiracy” among physicians, as I said yesterday, we’re basically talking about people having conversations with one another. The truth is the antitrust regulators don’t need much to establish a Sherman Act “conspiracy.” Even if there’s no evidence of direct communication between physicians, if a large number of physicians in a given market individually reject a government price control scheme or insurance company contract, the Antitrust Division can simply “infer” the existence of a conspiracy.

This is another reason why the DOJ’s presence in a physician case is more disturbing than the normal FTC case. The DOJ has a number of “tools” the FTC does not, including the self-granted power to award amnesties from criminal prosecutions to the first “conspirator” to step forward and provide evidence against one’s competitors.

A doctor that feared prosecution could seek amnesty — and provide the Justice Department a blank check to rummage through his files and private communications. And if that doesn’t work, the DOJ can always seek wiretaps of physicians’ phones and computers, a power awarded the DOJ during a 2006 renewal of the PATRIOT Act.

And while I usually caution against reading partisan political motives into an antitrust case — and I’d note the Idaho attorney general is a Republican — it’s hard to segregate today’s action from the larger political context of “Obamacare.”

Christine Varney is an Obama political appointee, and if the Idaho case is an indication her Division plans to take a more hands-on approach to dealing with local physician groups, this policy will quickly degenerate into political demagoguery. It’s just too easy to label physicians “price fixers” and scapegoat them for the failure of government planning of the healthcare industry.

UPDATE: The DOJ has released the proposed order and other documents. It’s a naked censorship order that restrains the physicians from

(A) encouraging, facilitating, entering into, participating in, or attempting to engage in any actual or potential agreement or understanding with, between, or among competing physicians about:

any fee, or other payer contract term or condition, with any payer or group of payers, including the acceptability or negotiation of any fee or other payer contract term with any payer or group of payers;

the manner in which the defendant or any competing physician will negotiate with, contract with, or otherwise deal with any payer or group of payers, including participating in or terminating any payer contract; or

any refusal to deal or threatened refusal to deal with any payer;

or

(B) communicating with any competing physician or facilitating the exchange of information between or among competing physicians about:the actual or possible view, intention, or position of any defendant or his or her medical practice group, or any competing physician concerning the negotiation or acceptability of any proposed or existing payer contract or contract term, including the negotiating or contracting status of the defendant, his or her medical group, or any competing physician with any payer or group of payers, or

any proposed or existing term of any payer contract that affects:

the amount of fees or payment, however determined, that the defendant, his or her medical practice group, or any competing physician charges, contracts for, or accepts from or considers charging, contracting for, or accepting from any payer or group of payers for providing physician services;

the duration, amendment, or termination of any payer contract; or

the manner of resolving disputes between any parties to any payer contract.

The order also illegally legislates through the courts by requiring the physicians to adhere to the 1996 Department of Justice and Federal Trade Commission Statements of Antitrust Enforcement Policy in Health Care, which is not law but merely the subjective opinions of unelected government antitrust lawyers. The order also requires the physicians to make “all books, ledgers, accounts, records, data, and documents,” available for government inspection at any time in the next ten years.

Since this is an DOJ case, it is subject to final approval by a federal judge in Idaho. There’s a mandatory 60-day public comment period, after which the judge will almost certainly rubber stamp the order as being “in the public interest.” Still, there’s at least an opportunity to express some serious dissent to what’s transpired here.

2ND UPDATE: It turns out the Idaho physicians hired the guy who used to run the Antitrust Division’s litigation department — and developed the government’s anti-physician antitrust rules — to represent them. No wonder they settled without a fight.

Beng a physician is no longer a "profession".We are controlled, regulated, villified, debased, and guilty to we prove our innocence.

My accountant and of course my lawer makes twice what I make despite my having far more training, education, legal risk, regulation to deal with, and stress.

I have to fight to get paid, I have to go through a quagmire of regs, mazes, fee collectors, billers, chase after pateints for even a few dollars, pay all of these people a cut just to get paid. I have to pay my accountant a much higher hourly rate just to get my tax refund due me from the government even though all she does is sit on her ass and write a letter, add and subtract, and fill out a form.

I could go on.

There are some doctors who abuse the system and while I don't condone that at least some of them justify doing it because of all the suffering we are made to go through.

All the while I go through this I see Bamster protecting lawyers. Not a peep about their corruption. Not one peep.

Katherine and I have gone what I have ad nauseum noted hear. And of course I am still expected to be a saint who loves medicine and just lives to provide the most humane best medical care to my patients and all the while agree with another scumbag lawyer named Chuck Schumer state all doctors should make no more than 80K a year. If that is what he wants there will be no one left in medicine other than nurses and Asians and Middle Easterners dying to come here and work for 100 hrs a week for ten cents. Then they will smarten up, realize this is not what they came here for and stop coming and many will go back to where they are from because it aint' worth it here.

Actually CCP being a physician IS still a profession. One that I admire greatly, much more than your accountant or lawyer.You can walk into any room, any place and be very proud.

I've said prayers of gratitude, sent cards, and bought gifts for many years for my surgeon at my birth and my wife's relatively recent surgeon. I merely "like" my lawyer and accountant. I like my plumber too.

I admit, life was easier years ago; my Grandfather was a successful surgeon; paperwork wasn't a big issue. Nor were rules and regulations.

However, don't despair, Physician income (see 2010 numbers below) is still up there. As a side note, and I would be curious about your opinion, physician wages do not seem to be predicated on medical knowledge and talent. Merely having the license to practice is enough. You can attend Harvard Medical School, or some Guadalajara Tech (I know doctors from both) and probably you will earn the same wage. In contrast to lawyerswho graduated near the top from Harvard Law and make big bucks, the guy who graduates from no name school will need to chase a lot of ambulances to make a good living. Or, they are very talented and on their own rise to the top. It is more of a meritocracy. The same applies to accounting. I know the trend is opposite of what I am suggesting, but I think doctors should be paid based on talent, not merely because they have a degree and put in the time. I like classical music; my very favorite teacher (as a side note, her husband is a traditional Cantor; we've had many wonderful "discussions" about Wagner and Van Karajan) has a Phd. from UCLA and has spent many years doing research. Yet she doesn't make close to $100K. Years in school should not be the only deciding factor.

For example, if you graduate from any Medical School, here in LA, you (general practice) are automatically offered a $125K+ job to start plus significant benefits. Graduate at the topof your class from one of 5-6 top Law Schools and you can start at over $200K. But, if you graduate from only an average Law School and aren't at the top of your class, you are lucky to get a job. Of course, the cream rises, but among physicians, ability and education does not necessarily translate into income. Graduate from Harvard Med. or Guadalajara Tech, your pay is near the same. Another words, you are guaranteed a good paying job evenin today's terrible economy.

On Monday, insurers that sell Medicare Advantage plans must submit their 2011 bids to the government. In a letter to four insurance-industry executives, Health and Human Services Secretary Kathleen Sebelius warned the companies not to increase premiums and co-payments for seniors.

"Focus on price and quality rather than asking seniors who need health care the most to pay more for it," Ms. Sebelius wrote in a letter sent Friday and reviewed by The Wall Street Journal. The letters went to WellPoint Inc., Cigna Corp., BlueCross BlueShield Association and Health Care Service Corp., according to a person familiar with the situation. Those executives met with Ms. Sebelius last month.

Many insurance companies are planning to increase costs for a range of services for seniors next year, according to consultants who have helped prepare their bids. Dozens of Medicare Advantage providers plan to cut back vision, dental and prescription benefits. Some plans are eliminating free teeth cleanings and gym memberships, and raising fees for hearing aides, eye glasses and emergency-room visits.

Consultants cite two reasons for the cuts. The rate the government will pay private insurers to run the plans is frozen for 2011 at 2010 levels, while medical costs are expected to increase an average of at least 6%. Such price increases and benefit cuts will help them recoup that difference, the consultants say.

Meanwhile, the health overhaul will impose drastic payment cuts to insurers that run the plans, and consultants say insurance companies need to begin adapting now. Starting in 2012, the law calls for a gradual reduction in government payments to insurers, totaling $136 billion before the end of the decade.

The Obama administration and Senate Democrats say that passing those costs on as early as next year is unfair. In her letter, Ms. Sebelius warned insurers that she will deny insurers bids if they include excessive price increases, using new powers under the health law.

Now why would Sebelius need to send a letter like this? Wasn't the Affordable Care Act supposed to, you know, make care more affordable? And didn't President Obama himself indicate that seniors needn't fear Medicare cuts? Or is this an admission that that, despite the administration's steady promises to the contrary, health insurance premiums are likely to go up in the wake of the new health care law?

Or maybe this letter is just a way of following through on those promises. The way the Obama administration will keep prices down and quality up is by...writing threatening letters to the health insurance industry warning them to keep service levels high and prices low.

If this is such a great idea, though, I wonder why we can try it for other industries? I propose we start with the video game console market: Let's make sure Microsoft puts out a next-generation Xbox pronto, and a stack of nifty new games to go with it. Obviously, though, I don't want to pay any more for it than a current console. Maybe the FTC and the FCC can take of this one with a joint-letter. And how about the wedding industry? Costs have gone up steadily over the years, and American families, already burdened by the effects of a sluggish economy, are suffering. If all it takes is a stern letter and a flash of some agency's regulatory weaponry to get more reasonable pricing and service out of the wedding planners and DJs and venue managers of the world, then surely this is a problem we can solve.

It's absurd, obviously, but hardly more so than what the Obama administration is doing here. Price controls on health insurance have already provoked a massive legal battle in Massachusetts, and the state's four biggest insurers are now all reporting operating losses—in large part, they claim, because of rate-hike rejections. Even Bill Clinton's economic advisers warned during the HillaryCare debates that imposing price controls would be difficult to implement and were likely to produce adverse effects. But those lessons appear not to have been passed on to the current administration, which seems determined to turn health insurance into an all-but government-run quasi-public utility.

Major Campaign to Sell ObamaCare - to You! This week, Politico and The New York Times published two devastating revelations:Multimillion Dollar Propaganda Campaign. According to Politico, White House allies, led by former Senate Majority Leader Tom Daschle and Victoria Kennedy, the widow of the late Senator Ted Kennedy, are set to unveil a $125 million public relations make-over for ObamaCare. This unprecedented propaganda campaign is designed to last until the law is fully in place in 2014 and to convince you and millions of your fellow countrymen that up is down, that black is white and that ObamaCare is good for you.

Advice to Candidates: Avoid Voters, Avoid Talking about Health Care. You're not likely to see TV images of candidates confronting angry voters at town hall meetings this summer. The reason? As The New York Times reports, members of Congress who voted for ObamaCare have "heeded the advice of party leaders and tried to avoid unscripted question and answer sessions." Among the recommendations to lawmakers: "Hold events in controlled settings...without the worry of being snared in an angry confrontation with seniors."

ObamaCare Propaganda Aimed at Seniors - Paid for with Your Tax Dollars! During the debate over ObamaCare, the Obama Administration threatened health insurance companies who informed seniors of the possibility that they could lose Medicare Advantage (MA) benefits. However, the health insurance companies were telling the truth. In fact, the information they used came from the Administration's Congressional Budget Office (CBO) and the Chief Actuary of Medicare. Medicare's Chief Actuary predicted that under ObamaCare as many as 7.4 million beneficiaries will lose their MA plan altogether and another 7.4 million will experience a loss of benefits. Incredibly, the forthcoming ObamaCare media blitz will target these seniors and claim that Medicare Advantage enrollees will be better off under ObamaCare.

Sebelius Threatens Insurers Publicly. ObamaCare stripped $200 billion from federal payments to Medicare Advantage plans. And no knowledgeable person is in doubt about the consequences of that. As one expert explained, "Washington can't slash $200 billion out of Medicare Advantage and then try to shift the blame...when those cuts inevitably result in higher premiums and benefit reductions for seniors." Nevertheless, on Monday Health and Human Services Secretary Kathleen Sebelius threatened health insurers, warning them not to increase premiums and co-payments when they submit their 2011 Medicare Advantage bids to the federal government. This is a clever ruse - getting ready to blame the victim for the results of a crime the administration has already committed.

The Vaunted Seniors' Rebate Check: Penny Wise... This week the Obama Administration will advertise its efforts to provide health care for seniors, citing a one-time, $250 health care rebate check that 80,000 seniors will receive this week and as many as four million may receive in the coming months. What the President won't mention is that the four million seniors who receive a check represents less than 10 percent of the Medicare population and that the seniors who benefit are among the nation's wealthiest Medicare beneficiaries. The check only goes to those not already receiving Medicare Extra Help. Finally, the rebate check comes in the midst of rising prescription drug costs for all seniors, not just 10 percent. As Senate Minority Leader Mitch McConnell explained earlier this week, "for every senior who receives a check, more than three other seniors will see an increase in their prescription drug insurance premiums."

...Pound Foolish. Not only will the President fail to distribute a check to 9 out of 10 seniors, but the one-time check pales in comparison to ObamaCare's pilfering of seniors' health care. According to the non-partisan Congressional Budget Office (CBO), ObamaCare cuts Medicare spending by $8,980 per senior over the next ten years. Consider also that:

The Chief Medicare Actuary Warns against Cuts in Senior Care. They urge that the Administration's planned $500 billion cuts in Medicare could jeopardize the access to care seniors receive.

The Chief Medicare Actuary Predicts Seniors Lose Coverage. They say that $206 billion in cuts to Medicare Advantage (MA) will result in 7.4 million beneficiaries who will lose their Medicare health plan.

The CBO Puts a Number on Lost Benefits. Seniors enrolled in Medicare Advantage (MA) will lose an average of $816 per patient in 2019. Premiums Will Rise, Says CBO. The CBO estimates that Medicare prescription drug coverage premiums will increase by 9 percent as a result of the Democrats' health law.

The NCPA Needs Your Help! The National Center for Policy (NCPA) vigilance comes at a price. We need your support to continue the important policy work that we do. Please consider donating to the National Center for Policy Analysis. You can donate online or mail a check to:

Not surprising since they feel he will push for primary care physicians to once again have a more central role in "managing" care and thus increase their power. Folks don't be fooled. "Patient centered care" or "patient centered medical home" care are other code words for government run/controlled *rationed* care. It is Federal *HMO* care for all of us whether we like it or not. As a primary care provider I suppose I should be rejoicing. Truthfully I am near tears every day at watching Bamster taking our freedoms all away. Essentially all of us will eventually be forced on to a Federally run HMO medicaid program.

The AAFP has praised the appointment of Donald Berwick, M.D., as the new administrator of CMS, saying in a prepared statement that Berwick's medical expertise and commitment to ensuring high quality care for all will serve America well as CMS implements the reforms in the Patient Protection and Affordable Care Act. "As a research professional, a clinician and a policy analyst, he brings an extensive background that’s crucial to ensuring that health care policy improves patient care and the practice of medicine," said AAFP President Lori Heim, M.D., of Vass, N.C., in the statement. "His leadership has helped ensure that best practices in medical care and groundbreaking medical research are brought to the physicians' offices, and his support for strengthening primary care in the Medicare and Medicaid systems will help set the path for building up the foundation of all high quality health care."

As CMS administrator, Berwick will serve as a key player in overhauling the nation's health care system by overseeing a variety of major tasks associated with the new health care reform law. Those tasks include expanding Medicaid coverage, writing new rules and regulations and establishing pilot projects to test different models of care and payment policies. Heim said the AAFP "looks forward to working with Dr. Berwick as the nation moves forward in ensuring that Americans have access to high quality, affordable health care."

President Obama used a recess appointment to make Berwick the new administrator of CMS on July 7, thereby circumventing a contentious confirmation process for the nomination in the Senate. Although Obama nominated Berwick for CMS administrator in April, Republicans were critical of the choice because they were concerned that Berwick could be a proponent of health care rationing. Republican opposition could have delayed the nomination indefinitely, prompting Obama to make a recess appointment while Congress is out of session.

The Senate had not scheduled hearings on Berwick's nomination, and White House Communications Director Dan Pfeiffer said in The White House blog on July 6 that "many Republicans in Congress have made it clear in recent weeks that they were going to stall the nomination as long as they could, solely to score political points."

In a prepared statement, Obama said, "It's unfortunate that at a time when our nation is facing enormous challenges, many in Congress have decided to delay critical nominations for political purposes." The president said the appointment would allow Berwick to "get to work on behalf of the American people right away."

Senate Republican Leader Mitch McConnell, R-Ky., accused the Obama administration of sneaking Berwick through without public scrutiny, saying in a prepared statement that "the Obama administration intends to arrogantly circumvent the American people yet again by recess appointing one of the most prominent advocates of rationed health care to implement their national plan."

Sen. Max Baucus, D-Mont., chair of the Senate Finance Committee, also criticized the Obama administration for not going through the standard nomination process. In a prepared statement, Baucus said, "Senate confirmation of presidential appointees is an essential process prescribed by the constitution that serves as a check on executive power and protects ... all Americans by ensuring that crucial questions are asked of the nominee -- and answered."

Nevertheless, Baucus said, "I look forward to working with CMS as they implement health reform to deliver the better health care outcomes and lower costs for patients we fought to pass in the landmark health reform law."

The AAFP supported the Berwick nomination from the outset, saying in a prepared statement in April that Berwick has "demonstrated a long-standing commitment to building a patient-centered, quality focused and efficient health care system." The Academy also put its signature on two widely circulated sign-on letters to Senate leaders supporting the Berwick nomination.

Berwick is a Harvard University professor and the president and CEO of the Institute for Healthcare Improvement, or IHI, a nonprofit organization in Cambridge, Mass., that advances concepts to improve patient care. He is a strong believer that physicians and hospitals can improve care while reducing medical errors and saving money. The AAFP has a long-standing relationship with Berwick through advocacy efforts in the public and private sectors and through its work and involvement with IHI.

Yeah, if you are not eating the goverment primary care giver's prescribed diet, of the properly prescribed foods, do not be surprised if you find yourself uncovered for failure to comply with prescripted health care..............

There is SO MUCH that is basically WRONG with this, it turns us into animals in a zoo in a lot of ways. The best of care, but we are suddenly unable to act like what we are.........like a tiger, ape or other animal in the zoo with the best in care, a long life over what it would have in the wild, but somehow totally pitiful...........

Good summary of what is in the plans for us with regards to Health care.

Take these for example from the new controller of one seventh of the economy, Berwick:

1) ***"One over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early."***Well if the issue is costs than this is probably true that these things are overrated. But this is my point. The concept of a medical home is not for prevention as much as it is a central point as a command center to manage care or ration care based on 'cost effective' formulas.

2) ****"Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy."***This is key. I don't know if it is obvious to lay people if you will, perhaps it is. But what this means is that doctors (and there patients) will not be granted the freddom to practice as they see fit in a given situation or case. Doctors and nurses will need to be "taught", if you will, or better yet forced, to do what they are told with regards to how and what care they deliver. And that is the big goal of HIT in health care. All of the data that gets put in will travel to Dr. Berwick's and team's office where he and his friends at Harvard will be able to study endless reams of data, and take there analysis, do studies, design studies, then dictate back to health care providers what they MUST do in any given situation.I don't necessarily object to this - it is managed care. What I object to is that all of us will be FORCED into this situation whether we like it or not, whether we are able and willing to pay more or not. Whether we have earned it, whether some abuse the system and the rest. IT is HMO medicaid care forced on every person in America whether a citizen, legal immigrant, or illegal immigrant. It is true communism of the health care system.

***Barack Obama's incredible "recess appointment" of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS) is probably the most significant domestic-policy personnel decision in a generation. It is more important to the direction of the country than Elena Kagan's nomination to the Supreme Court.

The court's decisions are subject to the tempering influence of nine competing minds. Dr. Berwick would direct an agency that has a budget bigger than the Pentagon. Decisions by the CMS shape American medicine.

Dr. Berwick's ideas on the design and purpose of the U.S. system of medicine aren't merely about "change." They would be revolutionary.

One may agree with these views or not, but for the president to tell the American people they have to simply accept this through anything so flaccid as a recess appointment is beyond outrageous. It isn't acceptable.

Daniel Henninger discusses President Obama's incredible "recess appointment" of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS).Podcast: Listen to the audio of Wonder Land here. The Democratic chairman of the Senate Finance Committee, Max Baucus, was taken aback at the end-around: "Senate confirmation of presidential appointees is an essential process prescribed by the Constitution that serves as a check on executive power."

Let's look, then, at what President Obama won't let the American electorate hear Dr. Berwick say in front of a committee of Congress. These excerpts are from past speeches and articles by Dr. Berwick:

"I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do."

"You cap your health care budget, and you make the political and economic choices you need to make to keep affordability within reach."

"Please don't put your faith in market forces. It's a popular idea: that Adam Smith's invisible hand would do a better job of designing care than leaders with plans can."

"Indeed, the Holy Grail of universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per capita costs."

"It may therefore be necessary to set a legislative target for the growth of spending at 1.5 percentage points below currently projected increases and to grant the federal government the authority to reduce updates in Medicare fees if the target is exceeded."

"About 8% of GDP is plenty for 'best known' care."

"A progressive policy regime will control and rationalize financing—control supply."

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AP Photo/ Goodman Media International, Inc.

Donald Berwick"The unaided human mind, and the acts of the individual, cannot assure excellence. Health care is a system, and its performance is a systemic property."

"Health care is a common good—single payer, speaking and buying for the common good."

"And it's important also to make health a human right because the main health determinants are not health care but sanitation, nutrition, housing, social justice, employment, and the like."

"Hence, those working in health care delivery may be faced with situations in which it seems that the best course is to manipulate the flawed system for the benefit of a specific patient or segment of the population, rather than to work to improve the delivery of care for all. Such manipulation produces more flaws, and the downward spiral continues."

"For-profit, entrepreneurial providers of medical imaging, renal dialysis, and outpatient surgery, for example, may find their business opportunities constrained."

"One over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early."

"I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care."

"Health care has taken a century to learn how badly we need the best of Frederick Taylor [the father of scientific management]. If we can't standardize appropriate parts of our processes to absolute reliability, we cannot approach perfection."

"Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy."

"Political leaders in the Labour Government have become more enamored of the use of market forces and choice as an engine for change, rather than planned, centrally coordinated technical support."

"The U.K has people in charge of its health care—people with the clear duty and much of the authority to take on the challenge of changing the system as a whole. The U.S. does not."

***There is no need to rehearse the analogies in literature and social thought that Dr. Berwick's ideas summon. That the Obama White House would try to push this past public scrutiny with a recess appointment says more about Barack Obama than it does Dr. Berwick.

Vilifying Dr. Berwick alone for his views is in a way beside the point. Within Mr. Obama's circle they all think like this. Defeat Dr. Berwick, and they will send up 50 more who would pursue the same goals.

If the American people want the world Dr. Berwick wishes to give them, that's their choice. But they must be given that choice with full, televised confirmation hearings.

Barack Obama, Donald Berwick and the rest may fancy themselves philosopher kings who know what we need without the need to inform or persuade us first. That's not how it works here. That is Sen. Baucus's point.

It should be clear why Berwick is bigger than Kagan. We need a large public debate over these views, over what Mr. Obama has said his health plan would and would not do. We need to find out if every Democrat in Congress and every Democrat writing newspaper columns and blogs agrees with Dr. Berwick about clinical and individual autonomy and about leaders with plans.

Then we need to build an election around whether we want to go down the road Dr. Berwick has planned for us, or start dismantling the one that President Obama paved through Congress on a partisan vote.

For years, an obscure federal task force sifted through medical literature on colonoscopies, prostate-cancer screening and fluoride treatments, ferreting out the best evidence for doctors to use in caring for their patients. But now its recommendations have financial implications, raising the stakes for patients, doctors and others in the health-care industry.

Under the new health-care overhaul law, health insurers will be required to pay fully for services that get an A or B recommendation from the U.S. Preventive Services Task Force, a volunteer group made up of primary care and public health experts.

That's good news for patients, who will no longer face cost sharing for these services, but it puts the group in the cross hairs of lobbyists and disease advocates eager to see their top priorities -- routine screening for Alzheimer's disease, diabetes or HIV, for example -- become covered services.

On Wednesday, first lady Michelle Obama; Jill Biden, the wife of Vice President Biden; and Health and Human Services Secretary Kathleen Sebelius discussed the importance of preventive care at a news conference to unveil regulations for implementing the provisions, which include coverage of immunizations and additional services for women and children.

"Too many Americans don't get the preventive care they need to stay healthy and keep health-care costs down for all of us," Sebelius said. "Our challenge is to remove the barriers."

The preventive-services task force will guide that effort. Founded in 1984, it has 16 members -- many of whom are doctors. The group meets three times a year and is staffed by officials at the Agency for Healthcare Research and Quality.

Under the new law, the task force could become a political lightning rod. If it doesn't recommend a service, insurers might not pay for it, and advocates might argue the decision is a barrier to care. If the panel does back a service, it might increase patients' access, as well as create new business opportunities.

The requirement applies only to plans created after Sept. 23. The Obama administration estimates that 31 million people in new employer plans, and 10 million people in new individual plans, will benefit next year. By 2013 the number of people in employer plans who will benefit is projected to reach 78 million, for a total of 88 million. Health department officials expect the provision will boost insurance premiums by about 1.5 percent.

The increased interest of advocates may conflict with the task force's tradition of scholarly dedication to the science of randomized medical trials.

"If you want to be evidence-based, lobbying just doesn't fit," said Ned Calonge, the panel's chairman and the chief medical officer for the Colorado Department of Public Health and Environment. "My charge to members would be to stay true to the methods and the evidence."

But sticking to the science hasn't always been popular. The task force set off a firestorm in November 2009 when, seemingly oblivious to the politically charged health-care debate, it recommended that women begin getting routine mammograms at 50, rather than at 40.

Critics pounced on the proposal, saying the government would engage in health-care rationing. Breast cancer activists also protested. The result: Sen. Barbara A. Mikulski (D-Md.) inserted an amendment in the health-care law to explicitly cover regular mammograms for women between 40 and 50.

Groups including the American Diabetes Association and General Electric, which manufactures equipment for mammography, also lobbied Congress on task force issues. The diabetes group won a requirement that the task force include in its reviews of evidence the guidelines drafted by specialty groups -- language intended to help preserve diabetes coverage.

In response to the backlash over the mammography recommendation and other calls for transparency, the task force recently adopted a new policy of accepting public comment before finalizing its recommendations.

Calonge said the task force was "willing to take on such challenges as increased scrutiny may bring forward." He said that while the panel wouldn't change its recommendations just because of criticism, it also would not be "immune" to input that might add perspective." But, he added, "the science needs to come first."

In addition to the task force, other scientific bodies and government groups will also help determine the services that must be covered. For instance, plans must also cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices, as well as screening practices for children that have been developed by the Health Resources and Services Administration in conjunction the American Academy of Pediatrics. Health plans will also be required to cover additional preventative care for women recommended under new guidelines that the Department of Health and Human Services is expected to issue by August 2011.

Several disease groups are going directly to HHS to make their cases.

The diabetes association, for instance, is arguing to the department that the current task force guidelines, which call for screening for diabetes only when a patient has elevated blood pressure, could become a barrier to care and that insurers should be required to provide broader coverage.

Lobbyist Tekisha Everette called the guideline "a shark in the water" and said her group has pressed Sebelius to include a broader diabetes screening requirement in regulations.

The HIV Medicine Association is making a similar argument. A two-page memo it delivered to the staff of the preventive services task force explains that one reason 20 percent of people with HIV don't know they are infected is that testing isn't reimbursed by most insurers.

Calonge said his panel's recommendation would only be used to set minimum coverage requirements and that insurers are free to cover additional services. The panel revisits its recommendations every five years.

Many commercial insurers already cover preventive services without cost sharing, often based on the task force's advice, according to Robert Zirkelbach, a spokesman for America's Health Insurance Plans, a trade group based in Washington. "There's broad recognition that prevention is essential," he said.

Weaver is a reporter for KHN (www.kaiserhealthnews.org), an editorially independent news service and a program of the Kaiser Family Foundation, a nonpartisan health-care policy organization that is not affiliated with Kaiser Permanente. Washington Post staff writer N.C. Aizenman contributed to this report.

"Too many Americans don't get the preventive care they need to stay healthy and keep health-care costs down for all of us," Sebelius said.

From Obama's new health czar or whatever he is called:

"One over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early."

As for the U.S. Preventive Services Task Force this was the group that stopped recommending mammograms for women at average risk between ages 40 and 50 that just last year resulted in a gigantic uproar from other medical groups, babe organizations, political pundits, that gave the cable industry a nice chance to make a buck discussing ad nauseum for months.

"As for the U.S. Preventive Services Task Force this was the group that stopped recommending mammograms for women at average risk between ages 40 and 50 that just last year resulted in a gigantic uproar from other medical groups, babe organizations, political pundits, that gave the cable industry a nice chance to make a buck discussing ad nauseum for months."Sorry already noted in the article posted by BBG.

And clarify:

" The concept of a medical home is not for prevention as much as it is a central point as a command center to manage care or ration care based on 'cost effective' formulas." Not my opinion. I meant that that is Berwick's opinion and overall goal.I can't wait to see the elites and their families at Harvard and in Congress, and the Senate have to go on managed medicaid like the rest of us. I am not holding my breath.

CCP; you of course are following the Health Care issues much closer than most here on this site.

I have a question.

I have a high deductible ($3500.00). Shit happens, but I can afford $3500. And my out of pocketis $5000; again manageable in case of emergency. And I am blessed with good health.

Coming from a family of medical practitioners, I chose (self employed) such a plan and still pay through the nose becauseI want to choose ANY doctor, any hospital, any procedure I may need or want without money being an issue. Nor if I am in a weakened state (seriously ill) do I want to argue. HMO's are different. For example,my naive, but loving wife, only 37 was diagnosed with Pancreatic Cancer. As you know, 95% die within 6 months. Without boring youwith the details, my wife has an HMO plan. I kept hearing "No", but as you and others on this site know I can be obnoxious I pushed, hard, and kept pushing (and I have a strong health/legal background) some more. The result is that she isdoing "fine" 3+ years later; she is back to work and we played golf together this last weekend. But after listening to "sorry", "she will die" etc. I am happy to say I got the best health care available and God willing she is doing fine. But it was a lot of work.

Sorry for the long story, but my question is, is there any mention of people being able to buy a supplemental planto "move you you to the head of the list" or being able to use the "back door" so to speak? Or most important, being ableto pick and choose your doctor, tests, etc.? I have a friend in England, a GP Internist like you, who says that they have a system like that. It supplements the National Health Care Plan. Is there any mention of that in the Obama Health Care Plan?

JDN,Thank you for sharing this story.My grandfather died of pancreatic cancer before I was born. My middle name is after him.

I do believe that if Berwick has his way your wife would likely have been sent to hospice.I don't think some sort of cost effective control is unreasonable when we are providing care free of charge courtesy of taxpayers to those who don't pay for whatever reason but I reject out of hand the notion that all of us must be forced into the same system and that is only FAIR as Berwick contends. I just cancelled my sbscription to the NEJM. I find THEM obnoxious!Health care is not a right. Yet, I don't think we can't be a humane society and provide some care to those who can't pay, but health care is never free and for those of us who do pay or choose to pay we have a right too, to get the best and not simply the most cost effective care.

Berwick, the little Harvard data and bean counting weasel will throw all kinds of numbers at you stating more is not necessarily better, and infant mortality, and life span and all the rest of liberal ivy league garbage. But I guarantee you, when he, his family or members of our fearless progressive government get sick they will want and demand world class care.

BTW, I don't find you obnoxious. We agree on a lot and I like diversity of opinion. I hope your wife continues to do well. Thanks to the US research complex there is always hope of new drugs coming out. Bamster should be going around the world (as well as this communist clown Berwick) praising US health care. It is broken but if one gets really sick I don't want to be anywhere else.

Thank you for your kind thoughts. You are not farfetched; even my wife's HMO initially suggested Hospice!

I think there should be some organized system for those who truly cannot pay; a safety net if you will rather than everyone simplyclogging the emergency room. However as far as I am concerned, regarding illegal immigrants, after they are able to be safely transported, send them back to their country of origin for further treatment.

But I also agree with choice and for those fortunate enough to have saved and pay their premiums, I think they should be able to have a choice to demand and receive world class care.

Some people drive a simple car; some drive a luxury car. Both will get you there, albeit luxury is better.

President Obama said earlier this year that the health-care bill that Congress passed three months ago is "essentially identical" to the Massachusetts universal coverage plan that then-Gov. Mitt Romney signed into law in 2006. No one but Mr. Romney disagrees.

As events are now unfolding, the Massachusetts plan couldn't be a more damning indictment of ObamaCare. The state's universal health-care prototype is growing more dysfunctional by the day, which is the inevitable result of a health system dominated by politics.

In the first good news in months, a state appeals board has reversed some of the price controls on the insurance industry that Gov. Deval Patrick imposed earlier this year. Late last month, the panel ruled that the action had no legal basis and ignored "economic realties."

Senior Editorial Page Writer Joe Rago on why Obama is using a recess appointment to install the new head of Medicare and Medicaid.

In April, Mr. Patrick's insurance commissioner had rejected 235 of 274 premium increases state insurers had submitted for approval for individuals and small businesses. The carriers said these increases were necessary to cover their expected claims over the coming year, as underlying state health costs continue to rise at 8% annually. By inventing an arbitrary rate cap, the administration was in effect ordering the carriers to sell their products at a loss.

Mr. Patrick has promised to appeal the panel's decision and find some other reason to cap rates. Yet a raft of internal documents recently leaked to the press shows this squeeze play was opposed even within his own administration.

In an April message to his staff, Robert Dynan, a career insurance commissioner responsible for ensuring the solvency of state carriers, wrote that his superiors "implemented artificial price caps on HMO rates. The rates, by design, have no actuarial support. This action was taken against my objections and without including me in the conversation."

Mr. Dynan added that "The current course . . . has the potential for catastrophic consequences including irreversible damage to our non-profit health care system" and that "there most likely will be a train wreck (or perhaps several train wrecks)."

Sure enough, the five major state insurers have so far collectively lost $116 million due to the rate cap. Three of them are now under administrative oversight because of concerns about their financial viability. Perhaps Mr. Patrick felt he could be so reckless because health-care demagoguery is the strategy for his fall re-election bid against a former insurance CEO.

The deeper problem is that price controls seem to be the only way the political class can salvage a program that was supposed to reduce spending and manifestly has not. Massachusetts now has the highest average premiums in the nation.

In a new paper, Stanford economists John Cogan and Dan Kessler and Glenn Hubbard of Columbia find that the Massachusetts plan increased private employer-sponsored premiums by about 6%. Another study released last week by the state found that the number of people gaming the "individual mandate"—buying insurance only when they are about to incur major medical costs, then dumping coverage—has quadrupled since 2006. State regulators estimate that this amounts to a de facto 1% tax on insurance premiums for everyone else in the individual market and recommend a limited enrollment period to discourage such abuses. (This will be illegal under ObamaCare.)

Liberals write off such consequences as unimportant under the revisionist history that the plan was never meant to reduce costs but only to cover the uninsured. Yet Mr. Romney wrote in these pages shortly after his plan became law that every resident "will soon have affordable health insurance and the costs of health care will be reduced."

One junior senator from Illinois agreed. In a February 2006 interview on NBC, Mr. Obama praised the "bold initiative" in Massachusetts, arguing that it would "reduce costs and expand coverage." A Romney spokesman said at the time that "It's gratifying that national figures from both sides of the aisle recognize the potential of this plan to transform our health-care system."

An entitlement sold as a way to reduce costs was bound to fundamentally change the system. The larger question—for Massachusetts, and now for the nation—is whether that was really the plan all along.

"If you're going to do health-care cost containment, it has to be stealth," said Jon Kingsdale, speaking at a conference sponsored by the New Republic magazine last October. "It has to be unsuspected by any of the key players to actually have an effect." Mr. Kingsdale is the former director of the Massachusetts "connector," the beta version of ObamaCare's insurance "exchanges," and is now widely expected to serve as an ObamaCare regulator.

He went on to explain that universal coverage was "fundamentally a political strategy question"—a way of finding a "significant systematic way of pushing back on the health-care system and saying, 'No, you have to do with less.' And that's the challenge, how to do it. It's like we're waiting for a chain reaction but there's no catalyst, there's nothing to start it."

In other words, health reform was a classic bait and switch: Sell a virtually unrepealable entitlement on utterly unrealistic premises and then the political class will eventually be forced to control spending. The likes of Mr. Kingsdale would say cost control is only a matter of technocratic judgement, but the raw dirigisme of Mr. Patrick's price controls is a better indicator of what happens when health care is in the custody of elected officials rather than a market.

Naturally, Mr. Patrick wants to export the rate review beyond the insurers to hospitals, physician groups and specialty providers—presumably to set medical prices as well as insurance prices. Last month, his administration also announced it would use the existing state "determination of need" process to restrict the diffusion of expensive medical technologies like MRI machines and linear accelerator radiation therapy.

Meanwhile, Richard Moore, a state senator from Uxbridge and an architect of the 2006 plan, has introduced a new bill that will make physician participation in government health programs a condition of medical licensure. This would essentially convert all Massachusetts doctors into public employees.

All of this is merely a prelude to far more aggressive restructuring of the state's health-care markets—and a preview of what awaits the rest of the country.

If you only glanced at Jesse Walker's one-sentence description this morning of the Obama administration stating that the health care mandate is indeed a tax, and did not click through to the New York Times article, you are missing out on some seriously stinky White House propaganda. Here is the core five-paragraph lie; seems that the mandate is "absolutely not a tax increase"...unless you have to defend it in a court of law:

In a brief defending the law, the Justice Department says the requirement for people to carry insurance or pay the penalty is "a valid exercise" of Congress's power to impose taxes.

Congress can use its taxing power "even for purposes that would exceed its powers under other provisions" of the Constitution, the department said. For more than a century, it added, the Supreme Court has held that Congress can tax activities that it could not reach by using its power to regulate commerce.

While Congress was working on the health care legislation, Mr. Obama refused to accept the argument that a mandate to buy insurance, enforced by financial penalties, was equivalent to a tax.

"For us to say that you've got to take a responsibility to get health insurance is absolutely not a tax increase," the president said last September, in a spirited exchange with George Stephanopoulos on the ABC News program "This Week."

When Mr. Stephanopoulos said the penalty appeared to fit the dictionary definition of a tax, Mr. Obama replied, "I absolutely reject that notion."

This bit of brazen bullshittery has retroactive implications on the 2008 presidential campaign. Back then, according to the political science thumbsucker The Obama Victory: How Media, Money, and Message Shaped the 2008 Election, John McCain–surprisingly–had some momentum in mid-October that threatened to put him within striking distance. The proximate cause? Obama's "share the wealth" comment to Joe the Plumber, and the resulting suspicion that the Democrat was a "tax-and-spend liberal." How did Obama rebut what turned out to be a prescient charge? The book identifies three ways:

1) By "consistently stat[ing] that only those couples and businesses making more than $250,000 would see a tax increase."

2) By "hammer[ing] home the misleading assertion...that, if elected, the Republican presidential contender would raise most people's taxes by making employer-provided health benefits taxable for the first time."

3) By leveraging Obama's massive fundraising advantage to broadcast a series of reassuring messages to the nation that made him look presidential and reiterated his many soon-to-be-broken economic policy promises. The two- and 30-minute spots were called "Defining Moment," and if you have a strong stomach, you can watch the shorter version below:

The Obama campaign also was able to take advantage of what the book almost charitably describes as "McCain's uneven performance during the early days of the Wall Street meltdown."

So to sum up: McCain accurately dings Obama for being a tax-raiser. Obama responds by reiterating tax pledges he wouldn't keep, while specifically (and "misleadingly") attacking McCain for raising taxes with his health care plan. The ruse works–for most of the campaign, opinion polls showed that more people believed McCain was likely to raise taxes than Obama. Then, after the election, when Obama's successfully passed health care plan imposes a new tax, he denies this fact in literally absolutist terms, until his administration is challenged to defend it in court.

It's breathtaking. And not in the good way.

A final note about the book I'm taking this stuff from: The authors, Kate Kenski, Bruce W. Hardy and Kathleen Hall Jamieson, are altogether credulous when it comes to defending Obama against McCain's charges. For instance, they state that "McCain's messages magnified public belief in the false argument that the Democratic ticket would raise taxes on more than those specified in his plans." It is perhaps not surprising, then, that when Jamieson was invited by The New York Times to give the president some advice over the weekend, the title on her squib was "Explain Broken Promises."

I spoke to a young lady from England recently. She states anyone can go to a doctor in England and it is "free". Five minutes later she says they all put in 11% of their pay into the National Health Care system.

Coincidentally, the woman from England who was touting the British system as being so good afterwards told of a new born nephew having mental status alterations.To make a long story short it took days to finally have a cat scan of her brain approved wherein they found a fractured skull and a bleed that they think was probably due to forceps injury during child birth. She later recanted and reportedly said that "maybe the British health care system is not so good".

If weasle Berwick has his way we will all have no choice. As far as progressives are concerned it is "inevitable". If not with this bill then the next one. Caveat emptor, Reid recently saying we will get a public option. [shoved down our throats]

As Congress debated the healthcare bill, many critics lamented it would do little to transform a system in which doctors and hospitals bounce patients around in an uncoordinated, costly, sometimes tragic process.

But something unexpected has happened since President Obama signed the legislation in March. Spurred in part by the law, many independent providers across the country are racing to mold themselves into the kind of coordinated teams held up as models for improving care. In some places, the scramble is so intense that physician groups and hospitals are putting aside rivalries and signing new partnerships almost daily.

"It's kind of like the Oklahoma land rush right now," said Patrick Carrier, a veteran hospital administrator who heads Christus Santa Rosa, a group of Catholic hospitals in San Antonio. "Everyone has their wagons lined up and they're getting ready to go."

Three of San Antonio's hospital systems are competing to form alliances with local doctors who are giving up their private fee-for-service practices in exchange for paid positions on a hospital's team.

Healthcare experts have long argued that such a unified approach to medical care offers the best hope for improving quality and saving money. While a few institutions such as the Mayo Clinic and Kaiser Permanente have thrived doing this, the entrenched, competing interests of providers were widely seen as a barrier to nationwide change. It is possible the current rush will fail to reproduce the best models or their results. Further consolidation in the $2.5-trillion healthcare industry might drive up costs for everyone. It could also reprise problems from the 1990s, when HMOs were criticized for restricting patient choice and access to care. But some experts and providers see the new courtship dances as a surprisingly hopeful sign. The healthcare debate may have helped spark doctors, hospitals and others to rethink what they do, raising the prospect of better outcomes for millions of Americans.

"There are a lot of people who have reached the conclusion that they need to change the way they practice medicine," said Dr. Mark B. McClellan, a former Medicare and Medicaid chief in the George W. Bush administration and a leading advocate of more care coordination.

In San Antonio, the leaders of the Christus Santa Rosa hospital have made that very calculation. Over nearly a century and a half, Santa Rosa's onetime infirmary a few blocks from the Alamo stanched cholera outbreaks and saved polio victims in a ward filled with iron lungs. But it operated on a fairly standard business model.

"We looked at our daily census, and if our beds were filled, we'd say, 'We're doing our job,'" Carrier said. "The more people we have in our beds, the more money we earn."

In Santa Rosa's cardiac telemetry ward, that is still the way it works. Recent patients included a 48-year-old man and a 71-year-old woman with congestive heart failure, and a 76-year-old woman with high blood pressure. Such chronic conditions, if treated properly, need not lead to a hospital stay.

The new law directs Medicare to reward alliances of healthcare providers, known as Accountable Care Organizations, or ACOs, if they reduce the cost of caring for patients like these while improving quality. That would likely mean fewer hospitalizations — and less income for Santa Rosa.

"In the new world, we're going to have to manage patients' diseases to manage expenses," Carrier said.

The best way to do that, he and others at Santa Rosa have concluded, is to work more closely with doctors, who now largely determine whom to admit to the hospital.

"Some folks are beginning to say that if you're not an ACO, you may not get paid at all," said Peter Maddox, senior vice president for strategy at Christus Health, the Catholic healthcare system that owns Santa Rosa.

Half a dozen times a week, Carrier meets with independently practicing doctors, talking with them about ways to collaborate and even trade their independence for a good pay package from Santa Rosa. And he's not alone.

"Every group of doctors I talk to is also talking to someone else," Carrier said.

Ultimately, Carrier said, Santa Rosa would like to put 100 primary care doctors on the payroll or in some other arrangement so the hospital and the doctors could manage patients' care jointly and benefit from incentives that Medicare and other insurers may offer.

Not everyone is interested in these overtures. Dr. Manuel M. Quinones Jr., who dissolved a partnership with Santa Rosa several years ago, said physicians should be wary. "When a hospital controls the lion's share, it will always be first in line to get the money," he said.

But like Carrier, many doctors in San Antonio see a changing world in which it's increasingly difficult to practice on their own.

"It's scary," said Dr. A. Charles Rabinowitz, a cardiologist who has watched many colleagues sell their practices. "There is a lot of paranoia out there."

Dr. C. Scott Horn, a family physician in suburban San Antonio, is carefully weighing offers from two hospital systems.

"I don't want to be told that I can only see a patient for 15 minutes," said Horn, the great-grandson of a Texas family doctor. "If someone comes in with an earache and tells me they're getting divorced and their life is falling apart, I'm not going to say, 'Sorry, make another appointment.'"

But practicing independently, Horn wrestles with multiple insurers, uncertain Medicare payments and new requirements to start using electronic health records. Though he has not decided what to do, he is intrigued by a different kind of healthcare model.

"It leads to the best medicine if the people delivering care talk to one another," the 63-year-old physician said. "That may be hard to get going. But in the long run, it's going to be better for patients."

Yes there is some shaking out going on. I understand that a lot of doctors are choosing early retirement too. Was it on this board where it was discovered that the healthcare bill was solving the GP crunch by doing a "government service period for payment of med school" sort of thing? When I was in the service there was a running joke that most of the active duty doctors had finished in the lower third of the med school classes........... I wonder if a similar situation would develop, "government" doctors would be insured federally, so they would be less diligent/competant?

Admitted market forces aren't doing a good job right now, but there is serious government meddling going on too, that has got to be diluting the mix........

yep, an inch of paperwork to get that sore throat checked. Is it a cold, Strep, Mono......... Instead of making an appointment, gagging on a swab, paying your 150$ and getting an answer in 3-4 days, after filling out 2 pages of mainly medical info.

Missouri voters on Tuesday overwhelmingly approved a measure aimed at nullifying the new federal health care law, becoming the first state in the nation where ordinary people made known their dismay over the issue at the ballot box.

The measure was intended to invalidate a crucial element of President Obama's health care law — namely, that most people be required to get health insurance or pay a tax penalty. Supporters of the measure said it would send a firm signal to Washington about how this state, often a bellwether in presidential elections, felt about such a law. The referendum drew support from 71 percent of nearly 939,000 voters. "My constituents told me they felt like their voices had been ignored and they wanted Washington to hear them," Jane Cunningham, a state senator and Republican who had pressed for a vote, said Tuesday night. "It looks to me like they just picked up a megaphone."

The referendum, known as Proposition C, was seen as a first look at efforts by conservatives to gather and rally their forces over the issue. Before the vote, the referendum had not appeared to to capture the general population's attention with any broad, statewide media campaign. Republican primary voters (who had the most competitive races on Tuesday) appeared to play a key role in the vote's fate; far more voters (577,612) cast ballots in the state's Republican primary for an open United States Senate seat as cast ballots for the Democratic candidates (315,787).Practically speaking, it remains entirely uncertain what effect the vote will have. The insurance requirement of the federal health care law does not come into effect until 2014. By then, experts say, the courts are likely to weigh in on the provision requiring people to buy insurance.

"While we're disappointed that Missourians didn't vote against this, we think the courts will ultimately decide it," said David M. Dillon, a spokesman for the Missouri Hospital Association.

For some, the outcome was not merely about health care, but about the role of states in setting policy.

"This really wasn't an effort to poke the president in the eye," said State Senator Jim Lembke, a Republican. "First and foremost, this was about defining the role of state government and the role of federal government. Whether it's here in Missouri with health care or in Arizona with illegal immigration, the states are going to get together on this now."

By GRACE-MARIE TURNER If Republicans take control of one or both houses of Congress this fall, many will have been elected with a promise to "repeal and replace" ObamaCare. But what are their options, really? There likely will be an initial showdown, but President Obama will surely veto any challenge to the law, and it would be hard to imagine mustering the votes to overturn it.

Information is the key weapon. Republicans can use congressional hearings to explain what ObamaCare is doing to the economy and the health sector. Their strongest cases would be built around jobs, the cost of health care, and the rising deficit.

If evidence shows that looming mandates on employers are crippling job-creation, they should be repealed. If health costs are rising, as they inevitably will be, Congress needs to hold hearings to investigate the causes and explain why the offending taxes and regulations must be repealed.

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Chad Crowe .Here are six key strategies that a Republican Congress could employ to put on the brakes:

• Defund it. House Republican Leader John Boehner of Ohio has vowed to choke off funding for implementation of the legislation, starting with parts that are especially egregious such as the "army of new IRS agents" needed to police compliance.

While Republicans could target the most damaging provisions of the legislation and tie their defunding measures to appropriations legislation that the president wants and needs to sign, they'd better be ready for battles. When former House Speaker Newt Gingrich lost a stand-down with President Clinton over closing down the government in 1996, it was widely seen as a setback for GOP efforts to scale back big government.

• Dismantle it. To focus committee action and floor votes, Republicans can look for provisions in the law that Democrats are on record as opposing. For example, Senate Budget Committee Chairman Kent Conrad (D., N.D.) has said that the new federal program to fund long-term care—the Community Living Assistance Services and Supports Act, or CLASS Act—is "a Ponzi scheme of the first order, the kind of thing that Bernie Madoff would have been proud of." Mr. Conrad and five of his Democratic colleagues sent a letter to Senate Majority Leader Harry Reid (D., Nev.) before the legislation passed opposing the program and expressing "grave concerns" about its fiscal sustainability.

Other highly unpopular provisions include the requirement that all businesses must file 1099 forms with the IRS to report any purchases totaling more than $600 in a year. This is designed to raise about $17 billion over 10 years from tax cheats. Rep. Dan Lungren (R., Calif.) was the first to introduce legislation to repeal this gigantic paperwork burden. Many Democrats in vulnerable districts who voted for the health law are also anxious to repeal this provision, which the National Federation of Independent Business says will impact 40 million businesses.

• Delay it. Republicans can also vote to postpone cuts to the popular Medicare Advantage program, postpone mandates requiring that individuals and businesses purchase and provide health insurance, and delay imposition of the $500 billion in taxes required by the law. Mr. Obama wouldn't likely sign such legislation, but the debate would shine a light on problems that haven't received nearly enough attention.

• Disapprove regulations. The Congressional Review Act of 1996 (CRA) gives Congress the authority to overturn regulations issued by federal agencies if both houses approve, with a two-thirds majority needed to override a presidential veto. This would be difficult to pull off. But proposing a resolution of disapproval under the CRA gives Republicans a platform to express strong disagreement and bring attention to especially egregious rules.

The current congressional majority wants to gut the CRA, and the House passed a bill that would eliminate the requirement that federal agencies submit their rules to Congress before they can take effect. The Senate has not yet acted, but this measure should be on the Republicans' watch list for the rest of the year.

• Direct oversight and investigation. Other aspects of ObamaCare are ripe for public hearings. For example, rules dictating how much insurance companies must spend on direct medical benefits are already hugely controversial—even before they have been issued. Businesses are also aghast at the narrow openings they have to protect their current health plans from onerous federal regulation. Republicans could summon many witnesses to testify about the impact of this regulatory straightjacket.

Congress also must keep a careful eye on the evolving cost estimates and deficits. Former Congressional Budget Office Director Douglas Holtz-Eakin estimates that the cost of the subsidies for private insurance could rise to $1.4 trillion —triple the $450 billion assumed by the current CBO. This is because the legislation creates strong incentives for businesses to drop coverage and dump their employees into federally subsidized insurance. Congress has a responsibility to protect taxpayers from what surely will be exploding costs.

Republicans also will want to call Donald Berwick, head of the powerful Centers for Medicare and Medicaid Services, to testify before Congress and detail his regulatory agenda for implementing the health-care law. He escaped that duty earlier this year when the White House avoided his Senate confirmation by giving him a controversial recess appointment.

• Delegate to the states. Congress should encourage states to press forward with their own innovative programs. For example, Gov. Mitch Daniels's popular and fiscally responsible Healthy Indiana Plan expands coverage to the uninsured using a health savings account model. And the lightly regulated Utah Health Exchange provides a marketplace for individuals and small businesses to purchase affordable, portable health insurance. Both are threatened by ObamaCare. The more that states are marching forward with reform that suits the needs and pocketbooks of their citizens, the easier it will be for Congress to repeal ObamaCare and start over.

Americans intuitively understand that government can't pay for huge new entitlement programs and the expansion of Medicaid with imagined cuts to Medicare, while still improving Medicare's long-term solvency. They also know that job creation is flat and that employers' fear of ever-rising health benefit costs is part of the problem. They need to hear the evidence that their fears are valid.

The real wallop of ObamaCare will come in 2014, when most of the spending begins and businesses and individuals are hit with intrusive and expensive mandates. The main job of Republicans, should they capture Congress, will be to slow down implementation of the law and explain to the American people the damage it will do—and already is doing—to our economy. If the White House changes hands in 2012, they can be ready to start with a clean slate and begin a step-by-step approach to sensible reform.